Although neurological conditions are not yet on the government's Hospital Readmission Reduction Program hit list, neurologists in forward-thinking health systems are preparing for the day they will be.
The Centers for Medicare & Medicaid Services (CMS) has proposed that, beginning in October 2015, stroke will be added to the list of medical conditions targeted by the readmissions program. Its decision will not be final for a few months, but those who are watching the government's focus on hospital readmission rates say it is only a matter of time.
“It is inevitable that this is going to happen for not just stroke, but also a variety of neurologic conditions,” said S. Andrew Josephson, MD, medical director of Inpatient Neurology at the University of California, San Francisco. “That's why we need to be ahead of the curve.”
Meanwhile, neurologists can have an important role in preventing readmissions even for inpatients who do not have a primary neurology diagnosis, said David Likosky, MD, a neurohospitalist at EvergreenHealth Medical Center in Kirkland, WA. For example, patients admitted for various diagnoses are prone to delirium, which is a risk factor for readmission.
Neurohospitalists can institute inpatient care protocols that help prevent delirium, as well as treat those patients that do develop it. In hospitals that do not have neurohospitalists, medicine hospitalists — and patients — need the expertise of neurologists.
“Many neurologists have ceded that type of care to medicine hospitalists but many, if not most, would be very interested in the assistance of a neurologist in helping set those systems into place,” he said. “Whether that's done just out of interest on the part of the neurologist or as a service reimbursed by the hospital administration, a neurologist can positively affect the care of those patients.”
WHY READMISSIONS MATTER
Health systems have been increasingly focused on 30-day readmissions since CMS first identified them as a marker of poor quality care several years ago. At that time, more than 20 percent of Medicare patients hospitalized for congestive heart failure, pneumonia, and heart attack were returning to the hospital within 30 days of discharge. CMS believed that many of those readmissions were avoidable if patients were properly supported so they could successfully transition to home or another care setting.
After a few years of prodding, CMS in 2012 started financially penalizing hospitals that have high 30-day readmission rates for those three conditions — and put everyone on notice that the penalties and the list of targeted conditions would increase in the years ahead.
While many physicians disagree with the CMS approach, most share the agency's goal of improving the quality of care. The quality movement has exposed the truth that hospitals are often dangerous sources of infection, falls, and other patient injuries, so minimizing hospital use — when appropriate — is good patient care.
Mark J. Alberts, MD, vice chair of clinical affairs and a professor in the department of neurology and neurotherapeutics at the University of Texas Southwestern Medical Center, said neurologists are primarily motivated to reduce readmissions because they want what is best for their patients. Notwithstanding readmissions that are planned, he agreed that reducing the likelihood of patients being readmitted is an appropriate measure of the quality of a patient's care.
“Readmission means that something unexpected happened in terms of the treatment not being adequate, or a new problem occurring, or some side effect occurring, and we want to avoid that in all patients,” said Dr. Alberts, who represents the AAN in discussions with CMS about its care initiatives. “This is independent of any business or government considerations.”
That said, some readmissions are unavoidable so it is not appropriate to count every readmission as a failure. “No medication or procedure reduces stroke risk to 0 percent, so some patients will have a recurrent stroke or transient ischemic attack,” he said. “A practical goal is to minimize readmissions; it is neither practical nor achievable to totally eliminate such events.”
HOW MEDICARE'S PROGRAM WORKS
The Hospital Readmissions Reduction Program (HRRP) is one of many new Medicare initiatives that tie hospital pay to the quality of care provided. In the fiscal year that began Oct. 1, 2012, CMS withheld up to 1 percent of regular Medicare reimbursements for hospitals that had “excess readmissions” for patients with heart attack, heart failure, or pneumonia for the three-year period from July 1, 2008, to June 30, 2011.
The penalty reflects a hospital's excess readmission ratio, which compares its readmission performance to the national risk-adjusted average for patients with those conditions. In the first year of the program, 2,213 hospitals received about $280 million in readmission penalties.
The second year of the program starts Oct. 1, reflecting readmissions for the three-year period ending June 30, 2012. The top penalty rises to 2 percent of total Medicare pay. CMS has announced that 2,225 hospitals will suffer $227 million in fines during the year, and the average fine will be .38 percent of a hospital's total Medicare reimbursement.
While the actual penalty amounts may seem negligible, the HRRP will become increasingly important to some hospitals' financial viability. For starters, the maximum penalty will rise to 3 percent in the third year of the program, and new conditions — chronic lung disease and elective hip and knee replacements — will be subject to readmission penalties.
Moreover, many hospitals are finding ways to reduce readmission. That raises the bar for all other hospitals, so those that do not effectively address readmissions will compare poorly with their peers and suffer larger penalties because of it.
FIRST UP: STROKE
CMS recently proposed that 30-day readmission rates for stroke patients be added to the Hospital Readmission Reduction Program in fiscal year 2016, which begins on Oct. 1, 2015.
Neurologists can see the CMS “dry run” data that shows each hospital's 30-day readmission rate for stroke patients for the three-year period ending June 30, 2011. Each hospital-specific report (HSR) shows the hospital's results along with state and national averages. Reports are available at CMS's QualityNet website (qualitynet.org).
Most readmissions are associated with remediable factors such as failure to take medicine as prescribed, a drug interaction or side effect, inability to afford prescriptions or an unexpected complication of their treatment, Dr. Alberts said. “All of these are identifiable and solvable issues.”
That is why the medicine hospitalists at EvergreenHealth conduct a chart review for every patient that is readmitted within seven days or 30 days of a discharge. They track the most common reasons for readmission among patients and experiment with process changes designed to improve patients' success after discharge.
Neurologists can decrease readmissions more than they might initially believe, Dr. Likosky said. The most critical practice, in his view, is making sure the patient has a timely follow-up appointment along with communication either verbally or through a discharge summary to facilitate a seamless care transition.
If a neurologist suspects that a patient will be unable to succeed at home, he or she should seek support from social workers or case managers than can help the patient understand the need for additional services and discuss the options available.
“Patients who are potentially near the end of life may be presented with options for hospice or with palliative care,” he said. “Presenting a realistic view of what's to come is important.”